Posttraumatic Stress in Primary Medical Care:  Insights and Interventions - PowerPoint Presentation

Slide1

Posttraumatic Stress in Primary Medical Care:  Insights and Interventions

Michael F. Barnes, Ph.D., MAC, LPCChief Clinical OfficerFoundry Treatment CenterSteamboat Springs, ColoradoSlide2

Why is Trauma Integration important?

According to the National Center for PTSD:

61% of men and 51% of women report having experienced at least

one traumatic event

(lifetime)

10% of men and 6% of women report having experienced four or more traumatic events (lifetime) (14% of middle class Americans!)Of these trauma victims, 8% receive diagnosis of PTSD1% of American population (New England Journal of Med)Women are diagnosed with PTSD twice as often as men.10% of Women & 5% of men will be diagnosedThere are multiple reasons for this: Biological, socialization issues, Type of trauma, age of trauma Slide3

What Kind of Events Cause Trauma?

Combat, First Responder

Natural Disaster Events - Hurricanes, Earthquakes, Tornadoes, Floods, Fires, etc.High Speed Events

- Car & Bike Accidents, Falls, etc.

Assault Events

- Assault, Rape, Incest, Animal AttacksGlobal Threat Events - Drowning, Electrocution, Caesarian, etc.Major Illness/Hospital Events - Cancer, Heart Attacks, AsthmaCyclical Trauma – Anniversary of major traumatic eventMajor Family Events - Divorce, Affairs, Death of a loved one, etc.Dysfunctional Family Systems (ACE Study)

Developmental or Attachment Trauma (Adverse Childhood Events – ACES)

Living in an alcoholic,

mentally ill, threatening, or otherwise dysfunctional familyIt’s not always what was done to you. Sometimes it’s what WASN’T done for you!Slide4

Significance of trauma for men – Be careful with Assumptions and Stereotypes

Men experience significantly higher rates of the following Potentially Traumatizing Events (PTE) (Tomlin & Foa, 2006) :

Accidents, Nonsexual Assaults, Combat, War, Terrorism, Disasters or FiresMen and Women -the same number of Nonsexual child abuse or neglect events.Women experience more child and adult sexual abuse

1 in 20 boys experience child sexual abuse

(National Center for Victims of Crime)

5%-10% of adult men can recall childhood sexual abuse event.1 in 71 (9%) men raped in adulthood (National Sexual Violence Resource Center)Men are typically assumed to be the perpetrator!In ACE Study - Childhood Sexual Abuse was reported by 16% of males and 25% of females.Males reported male perpetrator 60% of the time and female perpetrator 40%

Females

reported

male perpetrator 94% of the time and female perpetrator 6%Dube, Anda, Whitfield, Brown, Felitti, Dong, & Giles (2005)Slide5

Continuum of traumatic stress

Primary Trauma

(Primary Trauma Survivor)

Secondary Trauma

(Trauma Experienced by Family Members, Friends, First-Responders, Helping Professionals, etc.)

Compassion Fatigue

(Trauma Experienced by Care-Givers and Helping Professionals)

Organizational Trauma

Secondary Trauma

BurnoutSlide6

Introduction -

What is PTSD?

It is a:Bio-Psycho-Social-Spiritual Disorder

At its core, PTSD is a biological process that results in significant emotional, systemic, and behavioral consequences

.

Posttraumatic injury!Trauma Integrated addiction treatment MUST recognize the biological and systemic factors that maintain the disorder and identify appropriate interventions for treating each. Like Addiction, PTSD impacts families in the form of Secondary and Transgenerational Trauma!Slide7

DSM-5 Diagnostic Criteria for PTSD

Criterion A: Traumatic Event

How does someone get traumatized?Direct

personal experience

of an event that involves threatened death, actual or threatened serious injury, or threat to one’s physical integrity;Or witnessing an event

that

involves death, injury, or a threat to the physical integrity of another person

;Or learning about

unexpected or violent death, serious harm, or threat of death or injury

experienced by a family member or other close associates

;

Or

experiencing repeated or extreme exposure to aversive details of the traumatic event

(e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).

DSM VSlide8

DSM-5 Diagnostic Criteria for PTSD

Criterion B: Intrusion or Re-Experiencing

Intrusive thoughts or memoriesNightmares related to the traumatic event

Flashbacks, feeling like the event is happening again

Psychological and physical reactivity

to reminders of the traumatic event, such as an anniversaryCriterion C: Avoidant SymptomsAvoidant symptoms describe ways that someone may try to avoid any memory of the event, and must include one of the following:Defensive AvoidanceAvoiding thoughts or feelings connected to the traumatic eventAvoiding people or situations connected to the traumatic eventSlide9

DSM-5 Diagnostic Criteria for PTSD

Criterion D: Negative alterations in mood or cognitions

Decline in someone’s mood or though patterns following the traumatic event, which can include:Memory problems that are exclusive to the event (inability to recall key features)

Negative thoughts or beliefs

about one’s self or the world

Distorted sense of blame for one’s self or others, related to the eventBeing stuck in severe emotions related to the trauma (e.g. horror, shame, sadness)Severely reduced interest in pre-trauma activitiesFeeling detached, isolated or disconnected from other peopleCriterion E: Increased Arousal Symptomssymptoms are used to describe the ways that the brain remains “on edge,” wary and watchful of further threats. Symptoms include the following:Difficulty concentratingIrritability, increased temper or angerDifficulty falling or staying asleep

Hypervigilance and efforts to control

Being easily startledSlide10

Trauma and the Autonomic Nervous System

State 0

:

(zero): calm, responsive, awake

State 1

: slightly anxious, annoyed, nervous, physical tensionState 2: highly anxious, angry, panic symptoms, intense physical tension (stomach, chest, breathing), powerful fight or flight responses State 3: Dual activated (a mixture of activation with dissociative symptoms): tension with somatic collapse, anxiety, sleepy, panic, hopelessness, heaviness, blurred visionState 4: pure dissociation marked by a distinct lack of physical sensation and flat affect, numbed out, blank, feeling ‘floaty’, depersonalized, and disconnected

No Solutions

“Scared to death”

New NormalSlide11

Trauma Symptoms in Children and Adolescents

Toddlers and Preschoolers

Regressing behaviorsStuttering, muteness or speech delaysSleep disorders, nightmares, night terrors

Excessive clinging to parents, caregivers

Reenactment of the traumatic event, through play or aggression

Exaggerated startle responseTrauma related fearsImmobility or confusionIncreased sensitivity and poor sensorimotor integration.Elementary School Age StudentsAnxiety and worry about their own safety and the safety of other family membersWorry that “bad things” in the family will recurIncrease or decrease in activity levelEruptions of outbursts of angerDecrease in school attendanceIncreased incidents of headaches, stomach aches, and other pain.Profuse talk about what has happened.

Oversensitivity to sounds, smells, and other triggers

Change in appetite and sleep patterns

Irritability and whininess.Withdrawal from friends.Slide12

Trauma Symptoms in Children and Adolescents

Middle School Students

Anxiety and worry about their owns safety and the safety of other members of the family.Changes in academic performance and decreased school attendance.Increased bodily complaints and pain

Increased sensitivity to sounds, smells, and triggers

Loss of trust in family members or systems that failed the family.

Lessened interest in normal routine activitiesExpressions of defiance or deeper emotions (fear, anger, sadness.Sleep and appetite disturbances.Increased rebelliousness more at home/refuse to do chores.High School StudentsAny of the reactions of the middle school studentFeelings of vulnerability (which they may not like)Denial of the impactExhibit a more adult mannerBecome hypochondriacalBecome more irresponsible and even delinquent

Exhibit a lessening or increase in their emancipatory struggle

Become tense and exhibit appetite and sleep disturbances.Slide13

Individual Family Response: Secondary Trauma: Individual Family Member Reactions

(Barnes, 1995; Barnes, Todahl, & Barnes, 2002)

Anxiety Fear Anger

Intrusive thoughts about the traumatic event

Nightmares

FlashbacksHypervigilanceFeeling a need to control others behavior, the environment, their own feelings.Sleep disturbancesFatigueExperience a lack of feelings (numb) restricted feelingsFeeling detached or estranged from others.

Avoidance of activities that remind them of the trauma

Avoidance of places that remind them of the trauma

Family members report having experienced emotional, cognitive and behavioral symptoms that are similar to those reported by the primary survivor

.Slide14

10 Family Qualitative Study, Families of Patients with Chronic Co-Occurring Disorders (Mental Illness & Addiction)

Common

Feeling

Common

Defense

Mechanisms

Common

Behavioral

Responses

Anxiety/worry - hypervigilance/control Traumatic Stress Response Frustration with Medical Community

Anger

Fear Grief Guilt Horror Terror Shock Hurt Depression Frustration Shame

Denial Rationalization Intellectualization Projection

Common

Cognitive

Responses

Obsession Intrusive Thoughts Uncertainty Self Blame Fault Finding Resentments Hopelessness Helplessness

Fear of the Future

Common

Physical Responses

Sleeplessness Exhaustion Nightmares Startle ResponseHypervigilance Control–self/others Care Taking Impose Structure Avoid triggers & RemindersSlide15

Adverse Childhood Events – ACE Study

ACE Studies –

Typically include 10 specific types of ACES:Childhood Abuse

(Emotional, Physical, and Sexual)

Neglect

(Emotional and Physical)Witness domestic violenceParental marital discordLiving with substance abusing, mentally ill, or criminal household members)Original study included having a family member who was incarcerated

2/3 research participants reported one ACE in their childhood

Of those reporting 1 Ace 86% Were also exposed to at least 1 additional ACE

38.5% reported 4 or more additional exposures

(Dong, Anda, Felitti, Dube, Williamson, Thompson, Loo & Giles, 2004)

1 in 14 Middle Class Americans have 4 or more ACES

(

Felitti, et al. ,1998)

At substantially high risk for later morbidity and early mortalitySlide16

Adult Symptoms of Childhood Trauma (Schwartz, 2016)

Cognitive Distortions

(inaccurate beliefs about self, others, the World)

Emotional Distress

(Overwhelmed, Anxious, Helpless, Hopeless, Loneliness, Shame, Unfairness, Injustice, Depression, Suicidal Thoughts)Disturbing Somatic Sensations (Disconnect from body)Disorientation (Loss of orientation between the past, present, and future)Hypervigilance

Avoidance

Interpersonal Problems

(withdrawing from, blaming, pushing away, or criticizing friends and family. Patterns probably learned from family of origin)Reduced Brain Development

(Deficits in social skills and academic success)

Health Problems

(High blood pressure, blood sugar imbalances, food cravings, addictions, suppress immunity, digestive disturbances, sleep disturbances)

Problems with

Connection

,

Attunement to Personal needs

,

Trust

,

Autonomy/Boundaries,

and love/Intimate relationships (Heller & LaPierre, 2014)Slide17

Adverse Childhood Experiences (ACES) – Influence on negative health outcomes

60% of United States population have experienced at least one ACE (Centers for Disease Control and Prevention, 2010)

Individuals with ACES have higher likelihood of experiencing physical and/or psychological health consequences (Afifi et al., 2008)Alcoholism (7.4 x higher), IV drug use (11.3 x higher), Depression (4.5 x higher), Suicide attempts (12 to 15 x higher)emotional dysregulation, dissociation, poor attachment, Obsessive-Compulsive Disorder, Depression,

Often

engage in high risk behaviors that are often the cause of premature death

:including smoking, overeating, promiscuity, substance abuse, and self harm behaviors. Behaviors emerge as a means of coping with chronic stress associated with history of childhood trauma. (Garner, 2014).Heart Disease, Stroke, liver disease, lung cancer, COPD, rheumatoid arthritisSex with over 50 individuals, unwanted pregnancies, sexually transmitted diseases (Dube & Felitti, 2003)Hepatitis, Diabetes, CirrhosisSlide18

PTSD and Substance Abuse Disorders - Adult

Prevalence of PTSD and Substance Use Disorders

Bride (2007) - of treatment-seeking substance abusers: 60% to 90% have history of physical or sexual abuse

30% to 50% meet criteria for PTSD

Among persons who develop PTSD,

52% of men and 28% of women are estimated to develop an alcohol use disorder and 35% of men and 27% of women develop a drug use disorder (Najavits, 2007)The numbers are even higher for veterans, prisoners, victims of domestic violence, first responders, etc. (Najavits, 2004a, 2004b, 2007)

Individuals with PTSD are

3 to 4 times more likely to develop SUDs

than individuals without PTSD and have earlier histories with A & D, more severe use, and poor treatment adherence (Khantzian & Albanese, 2008)

Clients with PTSD/SUD are more vulnerable to poorer short- and long-term outcomes, more likely to relapse!Slide19

Protocol for Screening ACEs and other Traumatic Events in Primary Care Patients

Who should be screened for Trauma/ACES in Primary Medical Clinic

Patients with the following health problems:Obesity (current or past history)Gastro-Intestinal complaintsChronic diseases not well managed or patients who appear non-compliant with self-managementPTSD or known history of experience of traumatic eventsAnxietyDepression

Substance abuse disorders (including alcohol, elicit drugs)_

Patients in high-risk settings such as homeless shelters, women’s shelters, etc.

Patients with high health care utilization (Multiple complaints, 3 or more visits in 6 months)From E. Aponte 2017, Capstone Project, Umass Doctoral Program in NursingSlide20

Aponte Research Project – ACES Screening in OP Primary Medical Clinic

Diagnosis

Response

Response

%Count

Depression

39%

28

Anxiety

38%

27

Cardiovascular

31%

22

Diabetes

10%

7

Chronic Pain

17%

12

Chronic Respiratory14%10

Obesity11%8PTSD10%7Arthritis

8%6Bipolar8%6Substance Abuse

6%

4

ADHA

6%

4

Diagnosis

Average ACE

Score

PTSD

10.4

Substance Abuse

7.2

Depression

6

Anxiety

5.4

Bipolar

5.2

Chronic Pain

4.9

Chronic Respiratory

4.9

ADHD

4.8

Diabetes

4.3

Obesity

4.1

Cardiovascular

3.6

Arthritis

3.2

Using criteria above, survey of 71 adult clients of mixed age, race and gender.

58 (81.7%) reported at least one ACE Experience; 13 (18.3%) reported No ACES; Only 17 (24%) were in counseling of some typeSlide21

SBIRT for Trauma Related Issues

S

Screening

– Screening patients at risk for trauma related issues, PTSD, Adverse Childhood Events. Inquire about family history of traumatic events and the patient’s personal experience of traumatic events. Use screening tools such as the 4 Question Primary Care PTSD Screen and/or the 10 Question Adverse Childhood Events Questionnaire.

BI

Brief Intervention – Establish rapport with the patient. Introduce the significant influence that trauma related issues can have on the health of the trauma survivor. Ask if the patient would be willing to participate in a screening that could assist the medical team in identifying medical and therapeutic interventions that could address and alleviate both the traumatic stress and any associated medical conditions. Assess readiness to change; explore options for change, identify a plan for change, using Motivational Interviewing.RTReferral to Treatment – For patients who have responded positively to the screening instruments, refer for trauma therapy, addiction treatment, etc.Slide22

4 Question Primary Care PTSD Screen

The 4-question Primary Care PTSD Screen

In your life, have you ever had any experience that was so frightening, horrible or upsetting that, in the past month, you:*Have you had nightmares about it or thought about it when you did not want to? Yes or No

Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?

Yes or No

Were constantly on guard, watchful, or easily startled? Yes or No Felt numb or detached from others, activities, or your surroundings? Yes or No A score of 3 or higher should prompt additional evaluation. Source: Prins, et al. Primary Care Psychiatry. 2003Slide23

10 Question Adverse Childhood Experience (ACE) Questionnaire

While you were growing up, during your first 18 years of life:

Did a parent or other adult in your household often

. . .

Swear at you, insult you, put you down, or humiliate you?

OrAct in a way that made you afraid that you might be physically hurt If yes enter 1 ____Did a parent or other adult in the household often . . . Push, grab, slap, or throw something at you? OrEver hit you so hard that you had marks or were injured? If yes enter 1 ____Did an adult or person at least 5 years older than you ever . . . Touch or fondle you or have you touch their body in a sexual way

Or

Try to or actually have oral, anal, or vaginal sex with you? If yes enter 1 ____Slide24

10 Question Adverse Childhood Experience (ACE) Questionnaire

While you were growing up, during your first 18 years of life:

Did you often

feel that . . .

No one in your family loved you or thought you were important or special?

OrYour family didn’t look out for each other, feel close to each other, or support each other? If yes enter 1 ____Did you often feel that. . . You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? OrYour parents were too drunk/high to take care of you or take you to the doctor? If yes enter 1 ____Were your parents ever separated or divorced? If yes enter 1 ____Slide25

10 Question Adverse Childhood Experience (ACE) Questionnaire

While you were growing up, during your first 18 years of life:

Was your mother or stepmother . . . Often pushed, grabbed, or had something thrown at her?

Or

Sometimes or often kicked, bitter, hit with a fist or hit with something hard?

Or Ever repeatedly hit over at least a few minutes or threatened with a gun? If yes enter 1 ____Did you live with anyone who was a problem drinker/alcoholic/used street drugs? If yes enter 1 ____Was a household member depressed or mentally ill or did a household member attempt suicide? If yes enter 1 ____10. Did a household member to to prison? If yes enter 1 ____Slide26

How to take action on this issue

Make sure staff is knowledgeable about trauma, PTSD, ACES and trained on what to look for.

Designate which staff members will be talking to the patient and completing the Screening.Provide information about why you are screening for trauma related issues.”We know that childhood experienced can have long-term effects on adult health.”Ask the patient if they would be willing to participate in screening for trauma related issues. Be clear, concise, and non-judgmental when reviewing their answers..Respond with compassion

“I’m sorry/sad that this happened to you. How do you think t has impacted your health?”

When possible hire a behavioral health profession or have a therapist as a consultant, referral resource.

I have found it more likely that a patient will follow up if they are returning to the medical office for services.Know the treatment resources in your area for a wide variety of issues.Mental health resources (public & private), Addiction services (public & private)Slide27

Foundry Treatment Center

Michael F. Barnes, Ph.D., MAC, LPCChief Clinical OfficerFoundry Treatment CenterSteamboat Springs, Colorado303-885-1846

mike.barnes@foundrytreatmentcenter.com